Provider Demographics
NPI:1710319595
Name:JACKMAN, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:JACKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SEEKONK
Mailing Address - State:MA
Mailing Address - Zip Code:02771-1203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:607 PLEASANT ST
Practice Address - Street 2:SUITE 115
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-2570
Practice Address - Country:US
Practice Address - Phone:770-769-6562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health